Oral Vesicular and Bullous Lesions

Abstract

Vesiculobullous disorders involving the oral cavity may also affect the skin and other mucous membranes. They may thus reflect the oral manifestations of dermatological conditions, especially those which are immune mediated. Several different types of vesiculobullous disorders may present or be seen in the oral cavity, and it is important that they be recognized as distinct from the many other types of oral ulceration since they may represent systemic disease. Successful management depends on this recognition. Thus, careful histories, clinical examination, an understanding of the pathogenesis, and appropriate investigations are essential.

Several of the vesiculobullous lesions are immune mediated. The most common and serious are mucous membrane pemphigoid (MMP) and pemphigus vulgaris, both of which are type II, antibody-mediated conditions. In contrast erythema multiforme is thought to be an immune complex-mediated condition (type III), and bullous lichen planus is a cell-mediated initiated condition (type IV). The etiology of angina bullosa hemorrhagica remains enigmatic but does not appear to be immune mediated, whereas those of dermatitis herpetiformis and linear IgA disease are immune related, one showing deposition of dimeric IgA linked to gut disease and the other monomeric IgA and not related to gut disease.

There have been recent advances in the understanding of target antigens in the MMP group of diseases in particular, which partially elucidates the question of antigen specificity and clinical phenotypes. At long last, the oral medicine field has begun to embrace disease severity scoring and clinical outcome measures. This has allowed an evidence base to the efficacy of immunosuppressive therapies in the treatment of vesiculobullous diseases. The continued development of biologics has led to consideration of monoclonal antibody therapy as a first-line treatment in pemphigus and other conditions.

Modern laboratory techniques have allowed much investigation into both target antigens and isotype specificity of antibodies. These have allowed the identification of new disease phenotypes which in turn, with application of disease severity scoring, has given an evidence base to treatments. There has been much investigation of the use of saliva in diagnostics of vesicular bullous lesions which suggest that saliva will be useful as an adjunct fluid to serum and in some cases as an alternative. Pemphigus and MMP are reported in detail as archetypal examples of immune-bullous conditions.